Ann Thorac Surg 2006;81:1500-1502
© 2006 The Society of Thoracic Surgeons
Case report
Management of Acute Infrarenal Aortic Occlusion Secondary to Type A Dissection
Harvey Edward Garrett, Jr, MD
*
,
Bradley A. Wolf, MD
Division of Cardiothoracic Surgery, University of Tennessee, Memphis, Tennessee
Accepted for publication May 9, 2005.
* Address correspondence to Dr Garrett, 6029 Walnut Grove, Suite 401, Memphis, TN 38120 (Email: egarrettmd{at}cvsclinic.com).
 |
Abstract
|
|---|
Infrarenal aortic occlusion is a well described complication of type A aortic dissection that carries a significant mortality rate. A technique of immediate reperfusion of the lower extremities through an axillo–bi-femoral graft is described in 2 patients with good results.
|
Introduction
|
|---|
Type A aortic dissection is a common problem that results in infrarenal aortic occlusion on rare occasions, presumably when the false lumen compresses the true lumen without a re-entry point. Such patients present with two surgical emergencies (ie, life threatening dissection of the ascending aorta and limb threatening lower extremity ischemia). Moreover, cannulation of the femoral artery for cardiopulmonary bypass is no longer feasible.
Current practice would dictate repair of the aortic dissection with axillary artery cannulation for cardiopulmonary bypass. Correction of the aortic dissection entry site often corrects the malperfusion syndrome. However, when the malperfusion syndrome is not resolved, delayed lower extremity reperfusion may result in increased morbidity or mortality. After successful treatment of 2 such patients, a novel approach to this problem is reported.
|
Case Reports
|
|---|
Patient 1
A 69-year-old man presented to the emergency room with acute onset of paraplegia. An aortic dissection (type A) was found beginning just distal to the aortic valve and extending to the infrarenal aorta where acute occlusion of the aorta was identified by computed tomographic scan. No palpable pulses or doppler signals were present in the lower extremities. Cardiac catheterization revealed stenosis of the large diagonal coronary artery with no significant aortic valve insufficiency.
The patient was taken emergently to the operating room where an axillo–bi-femoral graft was tunneled between a right axillary incision and two femoral incisions. Using two surgical teams, anastomoses were completed to both femoral arteries while the sternum was opened for cardiopulmonary bypass. Arterial flow to the patient from the bypass machine was separated through a "Y"-connector on the operating table; one inflow cannula was placed into the axillary arteriotomy and the other into the proximal end of the axillo–bi-femoral graft. Arterial pressure was monitored through a left radial arterial line only. Cardiopulmonary bypass was instituted with flow to the head, neck, and torso through the axillary artery and immediate restoration of flow to the lower extremities through the axillo–bi-femoral graft (Fig 1). The ascending aorta was replaced with a Dacron tube graft, and the diagonal coronary artery was bypassed with a reversed saphenous vein graft. Cardiopulmonary bypass was terminated and the inflow cannulas were removed. The proximal axillo–bi-femoral graft was then sutured to the axillary arteriotomy, completing the lower extremity bypass. Bilateral lower extremity, four compartment fasciotomies were performed. The patient required reexploration for postoperative bleeding.
Lower extremity neurologic function gradually improved allowing discharge 3 weeks postoperatively at which time the patient could ambulate for 3 minutes with assistance. At 10 weeks he was ambulating independently. The left fasciotomy site was slow to heal. Four months postoperatively the arteriography showed a normal aorto-iliac system with complete resolution of the aortic occlusion. The axillo–bi-femoral graft had occluded, presumably as a result of competitive flow. Infrainguinal superficial femoral and popliteal disease was noted on the left and corrected with femoral-tibial bypass, resulting in complete healing of the fasciotomy site. The patient expired 18 months postoperatively secondary to metastatic prostate carcinoma.
Patient 2
A 40-year-old man with polycystic kidney disease and poorly controlled hypertension presented to the emergency room with chest pain and was found to have a type A aortic dissection by computed tomographic scan with 7 cm enlargement of his ascending aorta and distal aortic occlusion. The patient had ischemic lower extremities with absent femoral and pedal pulses.
He was taken to the operating room for emergent repair of the dissection and creation of an axillo–bi-femoral graft. Arterial inflow from the cardiopulmonary bypass machine was divided to the axillary artery and axillo–bi-femoral graft as previously described in the first case. Twenty minutes of circulatory arrest was required with retrograde cerebral perfusion. Surgical repair of the aortic dissection required replacement of the ascending aorta and aortic valve, with an aortic valve conduit. The left coronary ostium was reimplanted into the graft. The right coronary ostium was involved in the dissection and was oversewn. A reversed saphenous vein bypass was performed to the right coronary artery. The inflow cannulas were removed when the cardiopulmonary bypass was terminated. The proximal axillo–bi-femoral graft was sutured to the axillary arteriotomy, completing the lower extremity bypass. The patient required mediastinal reexploration for delayed tamponade. At 1 year follow-up, he has palpable pedal pulses.
|
Comment
|
|---|
Loss of peripheral pulses may occur in as many as 25% of patients with type A aortic dissection [1]. The mortality rate for patients who present with loss of peripheral pulses has been reported to be as high as 27% [1]. Malperfusion of visceral vessels also contributes to an increased mortality rate. Correction of the aortic entry site may result in restoration of peripheral pulses and resolution of malperfusion syndrome in 33% to 92% of patients [1, 2]. Reported solutions to persistent malperfusion syndrome after correction of the dissection entry point include extra anatomic bypass [3] and open and percutaneous aortic fenestration [2, 4, 5].
Delayed reperfusion is associated with increased mortality. Cambria and colleagues [2] reported 10 patients with aortic dissection who presented with infrarenal aortic obstruction, 9 of whom required open aortic fenestration. Six of these patients died [2]. The Mayo Clinic [5] reported a 20-year experience of malperfusion syndrome with only 3 patients with bilateral lower extremity ischemia, only 1 whose occurred with a type A dissection. These patients were treated with urgent open aortic fenestration; only 1 of the type B patients survived. Girardi and colleagues [6] reported an excellent outcome in patients with type A dissection and malperfusion syndrome treated with urgent replacement of the ascending aorta and delayed correction of persistent malperfusion syndrome by extra anatomic bypass or the fenestration procedure, or both. However, he had no cases of complete aortic occlusion. Reber and colleagues [7] reported 2 patients with distal aortic occlusions secondary to type B dissection, successfully corrected by a percutaneous fenestration procedure [6].
Most authors agree that prolonged end-organ ischemia can initiate an inflammatory cascade that may dramatically increase operative risk [8]. Although correction of malperfusion syndrome with a percutaneous fenestration procedure or extra anatomic bypass is an effective and successful option, there may be clinical situations in which the time delay required to correct the ascending aortic dissection and then perform a second procedure would be deleterious. Likewise, delayed repair of the ascending aorta is not advisable [8].
The axillary artery has been reported as a safe and effective site for arterial cannulation for cardiopulmonary bypass [9]. Simultaneous creation of an axillo–bi-femoral bypass allows immediate restoration of lower extremity perfusion without delay in correcting the dissection or waiting to complete the aortic replacement to ascertain the effect on the malperfusion syndrome. Rapid restoration of lower extremity perfusion minimizes ischemic injury and may have contributed to restoration of spinal cord function in the paraplegic patient.
Simultaneous axillo–bi-femoral bypass and replacement of the ascending aorta for type A aortic dissection complicated by infrarenal aortic occlusion allows immediate reperfusion of the lower extremities through divided arterial inflow from the cardiopulmonary bypass machine.
|
References
|
|---|
- Fann JI, Sarris GE, Mitchell RS, et al. Treatment of patients with aortic dissection presenting with peripheral vascular complications Ann Surg 1990;212:705.[Medline]
- Cambria RP, Brewster DC, Gertler J, et al. Vascular complications associated with spontaneous aortic dissection J Vasc Surg 1988;7:199-209.[Medline]
- Borst HG, Laas J, Heinemann M. Type A dissectiondiagnosis and management of malperfusion phenomena. Semin Thorac Cardiovasc Surg 1991;3:238.[Medline]
- Chavan A, Hausmann D, Dresler C, et al. Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta Circulation 1997;96:2124.[Abstract/Free Full Text]
- Panneton JM, The SH, Cherry KJ, et al. Aortic fenestration for acute or chronic aortic dissectionan uncommon but effective procedure. J Vasc Surg 2000;32:711-721.[Medline]
- Girardi LN, Krieger KH, Lee LY, et al. Management strategies for type A dissection complicated by peripheral vascular malperfusion Ann Thorac Surg 2004;77:1309-1314.[Abstract/Free Full Text]
- Reber D, Aebert H, Manke M, et al. Percutaneous fenestration of the aortic dissection membrane in malperfusion syndrome Eur J Cardiothorac Surg 1999;15(1):91-94.[Abstract/Free Full Text]
- Deeb GM, Williams DM, Bolling SF, et al. Surgical delay for acute type A dissection with malperfusion Ann Thorac Surg 1997;64:1669-1677.[Abstract/Free Full Text]
- Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary arteryan alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
S. M. Long III, D. Nair, P. M. Halandras, K. Kasirajan, R. Milner, and E. P. Chen
Ileofemoral Malperfusion Complicating Type A Dissection: Revascularization Prevents Renal Failure
Ann. Thorac. Surg.,
December 1, 2007;
84(6):
2099 - 2101.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
